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Using this fax form will expedite the prescription for the patient. Please complete the 4 steps below. Step 1 Patient Information Patient Name DOB Address Phone - City ST ZIP CVS Caremark ID Company Allergy Information Step 2 DRUG NAME Prescription Information STRENGTH DIRECTIONS QUANTITY REFILLS 1. Step 1 Patient Information Patient Name DOB Address Phone - City ST ZIP CVS Caremark ID Company Allergy Information Step 2 DRUG NAME Prescription Information STRENGTH DIRECTIONS QUANTITY REFILLS 1. 90 Days or 1 Year or Prescriber Signature Faxed By Substitution Permissible Unless Prescriber notes Brand Necessary or DAW on prescription Note Schedule II Controlled Substances cannot be submitted via fax. Fax 1-800-378-0323 PRESCRIBER SERVICES New Prescription Request FastStart Fax Form The following information is necessary in order to process your patient s prescription s. Using this fax form will expedite the prescription for the patient. Please complete the 4 steps below. Step 1 Patient Information Patient Name DOB Address Phone - City ST ZIP CVS Caremark ID Company Allergy Information Step 2 DRUG NAME Prescription Information STRENGTH DIRECTIONS QUANTITY REFILLS 1. 90 Days or 1 Year or Prescriber Signature Faxed By Substitution Permissible Unless Prescriber notes Brand Necessary or DAW on prescription Note Schedule II Controlled Substances cannot be submitted via fax. Step 3 Physician Information Required Dr. Name Fax - Step 4 Fax information toll-free to 1-800-378-0323 If you are not the intended recipient of this FAX you are hereby notified that any disclosure copying or distributing is prohibited* If you have received this FAX in error or if you would like to talk to our staff please notify us by phone toll-free at 1-800-378-5697. Plan participant privacy is important to us. Our employees are trained regarding the appropriate way to handle our plan participants private health information* 106-13946a. Fax 1-800-378-0323 PRESCRIBER SERVICES New Prescription Request FastStart Fax Form The following information is necessary in order to process your patient s prescription s. Using this fax form will expedite the prescription for the patient. Please complete the 4 steps below. 90 Days or 1 Year or Prescriber Signature Faxed By Substitution Permissible Unless Prescriber notes Brand Necessary or DAW on prescription Note Schedule II Controlled Substances cannot be submitted via fax. Step 3 Physician Information Required Dr. Name Fax - Step 4 Fax information toll-free to 1-800-378-0323 If you are not the intended recipient of this FAX you are hereby notified that any disclosure copying or distributing is prohibited* If you have received this FAX in error or if you would like to talk to our staff please notify us by phone toll-free at 1-800-378-5697. Step 3 Physician Information Required Dr. Name Fax - Step 4 Fax information toll-free to 1-800-378-0323 If you are not the intended recipient of this FAX you are hereby notified that any disclosure copying or distributing is prohibited* If you have received this FAX in error or if you would like to talk to our staff please notify us by phone toll-free at 1-800-378-5697. Plan participant privacy is important to us. Our employees are trained regarding the appropriate way to handle our plan participants private health information* 106-13946a. .

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